Past surgical history: Date and type of procedure performed, indication, and
outcome. Laparoscopy versus laparotomy should be distinguished. Surgeon
and hospital name/location should be listed. This information should be correlated with the surgical scars on the patient’s body. Any complications should
be delineated including, for example, anesthetic complications and difficult
intubations.
Past medical history:
a. Major illnesses such as hypertension, diabetes, reactive airway disease,
congestive heart failure, angina, or stroke should be detailed.
i. Age of onset, severity, end-organ involvement.
ii. Medications taken for the particular illness including any recent changes
to medications and reason for the change(s).
iii. Last evaluation of the condition (example: when was the last stress test
or cardiac catheterization performed in the patient with angina?)
iv. Which physician or clinic is following the patient for the disorder?
b. Minor illnesses such as recent upper respiratory infections.
c. Hospitalizations no matter how trivial should be queried.
The first line of any presentation should include age, ethnicity, gender, and chief complaint. Example: A 32-year-old white man complains of lower abdominal pain of 8-hour duration.
Basic information
a. Age: Some conditions are more common at certain ages; for instance, chest pain in an elderly patient is more worrisome for coronary artery disease than the same complaint in a teenager.
b. Gender: Some disorders are more common in men such as abdominal aortic aneurysms. In contrast, women more commonly have autoimmune problems such as chronic idiopathic thrombocytopenic purpura or systemic lupus erythematosus. Also, the possibility of pregnancy must be considered in any woman of childbearing age.
c. Ethnicity: Some disease processes are more common in certain ethnic groups (such as type II diabetes mellitus in the Hispanic population).
